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Unlisted Face or Jaw Prosthesis Service

Montana rates for HCPCS 21089

Covers the making or fitting of an artificial replacement for a missing or damaged part of the face, jaw or mouth when no standard named service applies. These custom devices restore appearance and function after cancer surgery, injury, or a condition present from birth. Because each one is built for a single person, the specialist records exactly what was designed and fitted.

Rates data updated July 2026.

Facilitymedian $631 · 10th–90th $501$6920%50%10th90th$631Professionalmedian $85 · 10th–90th $79$6920%50%10th90th$85$100.0$200.0$500.0

Distribution of negotiated rates across all payers (price axis is log-scale). Facility and professional rates are different services and are charted separately. Small sample; interpret with caution. Need provider-level prices? Contact us.

Insurance Carrier
MountainHealth Co-op
Setting
Facility
Modifier
Global
Typical Low
$501.19
Median
$630.96
Typical High
$691.83
MountainHealth Co-op
Setting
Professional
Modifier
Global
Typical Low
$501.19
Median
$630.96
Typical High
$691.83
Providence
Setting
Professional
Modifier
Global
Typical Low
$60.26
Median
$79.43
Typical High
$85.11